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BACKWATER PREVENTION DEVICE FINAL <br />INSTALLATION CHECKLIST <br />Installatiai Company Name and Conlad Info: � b 2—� ,� d 1 Z-�'— <br />Date Badcwater Prevendon device (BWD) was installed: � Date this form was completed:1 /—��l 2��7 <br />PropeAy Address: �P / 3 �� �� f'1 /.e V <br />Prcdintallation Inspectlon Checldist: <br />Aq ifems musf 6e checked'Yes' in order for a BWD to 6e considered lor inslaNafion <br />Is there a basement or level of the house ihat is at or rrear assumed sewer mein elevation? �s ❑ No <br />Are there fixtures in Ihe house located below the upstream sewer manhole rim elevation? [�� � No <br />Is ihe side sewer currently UNPROTECTED from sewer backups (dces not have a BWD installed)7 [t�'fes ❑ No <br />Site Inspection Checklist: <br />Atl items musf 6e checked'Yes' be%re Inspection is considered complete <br />Was side sewer N inspected from building to sewer main? es ❑ No Condition: � G ' <br />Does side sewer have at least i°h stope from the building to sewer main9 [�]'f�^ ❑ No Descx�e: <br />Have all building sewer d�ain connections lo the side sewer been identified and localed7 �Yes � No <br />Heve all property slorm drainage cc•:nections to ihe side sewer been idenlified and located? ��'f�s ❑ No <br />Has propeAy been evaluated tor drainage deficienaes wilh findings communicated to properly ownei? 0� ❑ No <br />Inslalladon Details: <br />What lype and brand of BWD was inslailed at this site (Clean Chedc BVW, Grinder pump, elc.): <br />. . <br />Where was tha <br />Was there any other sewer <br />(general desaiplion, atlach map)? <br />� r a�.2. 'Z> � aY4 <br />o. drainage work comp ed in a <br />lion wilh the BWD work7 Is so please desaibe: _ <br />� <br />InsWllallon Cheeklist: <br />Are all downspouts and site drainage disconneGed from upstream of ihe BWD7 es ❑ No Comments: <br />Does BWD positioning meets minimum slope requirement ot>1°%? �s ❑ No Commenls: <br />Can BWD be pulled out for inspection and maintenance after loosening thumb screw? es ❑ No <br />Is BWD locked inro the proper positio thum ew lightened4 es ❑ No <br />Ciicle the BWD cove irti ation cover an flic load bearing cover (drive surface)1 access hatch (building) <br />Was prope�ty owner shown Ihe location of the installed BWD? es ❑ No Commenls: <br />/ � --�/ ��� <br />Property Owner's Signaturd: `"�� � �---_- Date: /( - �� - �`"� _ <br />Installer's Signeture: Date: �� / i' � <br />Revision: 2 1 Friday, September 12, 2014 <br />